Polycystic Ovarian Syndrome Flashcards
What is PCOS?
Polycystic ovarian syndrome (PCOS) is a common condition causing metabolic and reproductive problems in women. There are characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance.
What is anovulation? Oligoovulation? Amenorrhoea? Oligomenorrhoea? Androgens? Hypradrogenism? Hirsutism? Insulin resistance?
Anovulation refers to the absence of ovulation
Oligoovulation refers to irregular, infrequent ovulation
Amenorrhoea refers to the absence of menstrual periods
Oligomenorrhoea refers to irregular, infrequent menstrual periods
Androgens are male sex hormones, such as testosterone
Hyperandrogenism refers to the effects of high levels of androgens
Hirsutism refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair
Insulin resistance refers to a lack of response to the hormone insulin, resulting in high blood sugar levels
What criteria is used in the diagnosis of PCOS?
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)
TOM TIP PCOS?
TOM TIP: If you are going to remember one thing about polycystic ovarian syndrome, remember the triad of anovulation, hyperandrogenism and polycystic ovaries on ultrasound. The Rotterdam criteria are commonly tested in MCQs and asked by examiners in OSCEs. It is important to remember that only having one of these three features does not meet the criteria for a diagnosis. As many as 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.
How do patients with PCOS present?
Women with polycystic ovarian syndrome present with some key features:
Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern
In addition to the presenting features, women may also experience:
Insulin resistance and diabetes Acanthosis nigricans (thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance) Cardiovascular disease Hypercholesterolaemia Endometrial hyperplasia and cancer Obstructive sleep apnoea Depression and anxiety Sexual problems
Differential diagnosis of hirsutism?
An important feature of polycystic ovarian syndrome is hirsutism. Hirsutism can also be caused by:
Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia
How is insulin resistance related to PCOS?
How is it treated?
Insulin resistance is a crucial part of PCOS. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.
The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
Diet, exercise and weight loss help reduce insulin resistance.
What are the investigations for PCOS?
NICE recommend the following blood tests to diagnose PCOS and exclude other pathology that may have a similar presentation:
Testosterone Sex hormone-binding globulin Luteinizing hormone Follicle-stimulating hormone Prolactin (may be mildly elevated in PCOS) Thyroid-stimulating hormone
Hormonal blood tests typically show:
Raised luteinising hormone Raised LH to FSH ratio (high LH compared with FSH) Raised testosterone Raised insulin Normal or raised oestrogen levels
TOM TIP: The key thing to remember for your exams is the raised LH, and the raised LH:FSH ratio.
Pelvic ultrasound is required when suspecting PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either:
12 or more developing follicles in one ovary
Or ovarian volume of more than 10cm3
TOM TIP: It is worth remembering the “string of pearls” description for your exams. It may come up in MCQs. It is also worth remembering that an ovarian volume of more than 10cm3 can indicate polycystic ovarian syndrome, even without the presence of cysts.
The screening test of choice for diabetes in patients with PCOS is a 2-hour 75g oral glucose tolerance test (OGTT). An OGTT is performed in the morning prior to having breakfast. It involves taking a baseline fasting plasma glucose, giving a 75g glucose drink and then measuring plasma glucose 2 hours later. It tests the ability of the body to cope with a carbohydrate meal. The results are:
Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
Diabetes – plasma glucose at 2 hours above 11.1 mmol/l
What is the general management of PCOS?
It is crucial to reduce the risks associated with obesity, type 2 diabetes, hypercholesterolaemia and cardiovascular disease. These risks can be reduced by:
Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)
Patients should be assessed and managed for the associated features and complications, such as:
Endometrial hyperplasia and cancer Infertility Hirsutism Acne Obstructive sleep apnoea Depression and anxiety
Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.
Which cancer are women with PCOS at increased risk of?
Why?
Women with polycystic ovarian syndrome have several risk factors for endometrial cancer:
Obesity
Diabetes
Insulin resistance
Amenorrhoea
Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
How is the risk of endometrial cancer managed in PCOS?
Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.
Options for reducing the risk of endometrial hyperplasia and endometrial cancer are:
Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill
How is infertility managed in PCOS?
Weight loss is the initial step for improving fertility. Losing weight can restore regular ovulation.
A specialist may initiate other options where weight loss fails. These include:
Clomifene
Laparoscopic ovarian drilling
In vitro fertilisation (IVF)
Metformin and letrozole may also help restore ovulation under the guidance of a specialist; however, the evidence to support their use is not clear.
Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
Women that become pregnant require screening for gestational diabetes. Screening involves an oral glucose tolerance test, performed before pregnancy and at 24 – 28 weeks gestation.
How is hirsutism managed in PCOS?
Weight loss may improve the symptoms of hirsutism. Women are likely to have already explored options for hair removal, such as waxing, shaving and plucking.
Co-cyprindiol (Dianette) is a combined oral contraceptive pill licensed for the treatment of hirsutism and acne. It has an anti-androgenic effect, works as a contraceptive and will also regulate periods. The downside is a significantly increased risk of venous thromboembolism. For this reason, co-cyprindiol is usually stopped after three months of use.
Topical eflornithine can be used to treat facial hirsutism. It usually takes 6 – 8 weeks to see a significant improvement. The hirsutism will return within two months of stopping eflornithine.
Other options that may be considered by a specialist experienced in treating hirsutism include:
Electrolysis
Laser hair removal
Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
Finasteride (5α-reductase inhibitor that decreases testosterone production)
Flutamide (non-steroidal anti-androgen)
Cyproterone acetate (anti-androgen and progestin)
How is acne managed in PCOS?
The combined oral contraceptive pill is first-line for acne in PCOS. Co-cyprindiol (Dianette) may be the best option as it has anti-androgen effects; however, there is a significantly increased risk of venous thromboembolism.
Other standard treatments for acne include:
Topical adapalene (a retinoid)
Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline antibiotics (e.g. lymecycline)
